A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.

The triage nurse does a rapid assessment of the client.

1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Click to highlight the data that indicate the client is in need of immediate health interventions.

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.

Choice A rationale:

“I should take this medication with food to prevent stomach upset.” Rationale: This statement is not accurate for fluconazole. While some medications should be taken with food to reduce stomach upset, fluconazole is typically taken on an empty stomach. Taking it with food may reduce its absorption.

Choice B rationale:

“I should avoid drinking alcohol while taking this medication.” Rationale: This is the correct response. Fluconazole can interact with alcohol and may lead to increased side effects or reduced effectiveness of the medication. Therefore, it is essential to avoid alcohol while taking fluconazole.

Choice C rationale:

“I should use a barrier method of contraception while taking this medication.” Rationale: While it is generally a good practice to use barrier contraception during treatment for a fungal infection to prevent potential spread to a partner, this statement does not specifically address fluconazole's requirements or interactions.

Choice D rationale:

“I should stop taking this medication if I develop a rash.” Rationale: This statement is not entirely accurate. While it is important to monitor for skin rashes as they can be a sign of an allergic reaction, the decision to stop taking fluconazole should be made in consultation with a healthcare provider. It is not an automatic response to developing a rash.